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Ankle Pain After a Sprain
Chris Van Hofwegen MD
Dept. of Orthopaedics
8/23/07
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Case #1
• 25yo healthy male playing basketball steps on another player’s foot and rolls his ankle.
• What other information do you need to know?
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P.E.
• Special tests?
• Significance?
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Anterior Drawer Stress Test
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Talar Tilt
• Talar Tilt (CFL)
• Difficult to isolate from subtalar ROM
• Slight plantar flexion (dorsi = relative subtalar isolation)
• Compare to opposite side
• 5° greater than opposite side or 10° absolute value
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Lateral Ligament Instability
• ATFL – resists inversion in plantarflexion
• CFL – resists inversion in neutral or dorsiflexion
• PTFL - resists posterior and rotatory subluxation of the talus
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Lateral Ligaments
ATFL
CFL CFL
ATFL Leg
Foot
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Posterolateral Ligaments
CFL
PTFL
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• After physical exam?
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Ottawa foot/ankle rules
• Prospectively validated data– Reduces unnecessary radiographs by 30% in
ER– Requires 1 positive to order an XR
• Tender points (4)
• Ability to bear weight (4 successive steps)
• Age over 55
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Ottawa foot/ankle rules: Tender zones indicating XR’s needed
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Grading
• Grade 1 – Stretching of ATFL– Mild tenderness.– No evidence of mechanical instability.
• Grade 2 – Complete tear of the ATFL and partial injury of CFL. – Moderate tenderness.– Moderate laxity with anterior drawer, talar tilt test normal.
• Grade 3 – Complete rupture of ATFL and CFL.– Severe tenderness.– Anterior drawer test and talar tilt test grossly positive.
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Nonsurgical Treatment
• Treatment of choice for all grades of lateral ankle ligamentous injury.
• Grades 1 and 2– Elastic wrap, short period of weight-bearing
immobilization in a removable boot, ice, range-of-motion exercises.
– Neuromuscular training – peroneal muscle and proprioceptive training
• Grade 3– Extended period of immobilization in weight-bearing
boot may be necessary.
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What does the literature say?
• 9 RCTs (level 1 evidence) comparing functional bracing to cast immobilization in the treatment of acute ankle sprains (grade not specified)
• Results for 5 outcomes:– Return to work/sport: roughly equivalent (about
90%)– Time to return to work: functional bracing
slightly better in 4/5 studies
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What does the literature say?
• Results (continued):– Subjective instability: slightly better for bracing
in 3/5 studies– Reinjury: Better with bracing (RR=0.5-0.84)– Satisfaction: Better with casting (20% versus 5-
15%)
– Jones, Amendola. CORR. 2007.
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Sequelae of ankle instability
• Up to 60% of patients continue to experience symptoms.
• Instability – Muscular weakness – neuromuscular rehab– Ligamentous instability - surgery
• Pain - continue the search
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Case #2
• 17yo female with lateral ankle pain for 3 years after a left ankle sprain. She may have tweaked it a couple of times but can’t quite remember. She played volleyball in braces and tolerated it okay, but now her foot bothers her most of the time.
• PMHx: healthy• PE: tender laterally over sinus tarsi
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What’s the differential diagnosis?
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Differential Diagnosis
– Fracture of the lateral process talus– Fracture of anterior process calcaneus– Osteochondral injury– Loose body– Peroneal tendon tear– Peroneal tendon subluxation– Traction injury to SPN– Arthritis
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What does our patient have?
• XR:
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Tarsal coalition
• What is it?
• Not completely known but it seems to be a failure of segmentation of tarsal bones and formation of normal articular cartilage
• Circumstantial evidence from fetal feet shows intertarsal bridging supporting that etiology
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Tarsal Coalition
• Incidence: 1% - unknown how many are asymptomatic with a coalition
• Bilaterality: 50-60%
• Genetics: autosomal dominant with high but not complete penetrance
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Tarsal coalition
• Radiographic signs– Anteater– Talar beaking– C-sign
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Tarsal coalition
• Treatment– Conservative
• Period of casting
• Inserts
– Surgical• Calcaneonavicular – resection with EDB
interposition graft
• Talocalaneal – resection with fat graft versus fusion
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END
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Instability
• Mechanical – ligamentous laxity
• Functional – muscular weakness
• Initial treatment involves therapy program for peroneal muscle strengthening and proprioceptive training.
• Successful in 90%
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Gould Modification of Broström Repair
• ATFL, CFL = condensations of capsule
- usually attenuated, elongated
• Direct repair (shortening) of ATFL, CFL
• Reinforce repair with
(i) inferior extensor retinaculum
(ii) periosteal sleeve distal fibula
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Gould Modification of Broström Repair
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Outcomes of Modified Broström
• 91% good or excellent
Messer, 2000 FAI
• 27/28 good or excellent
Hamilton, 1993 FAI
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Mechanism
• Position of instability in plantar flexion and inversion.
– Narrow diameter of the talus posteriorly.
• Failure of:
1. Anterolateral joint capsule
2. ATFL
3. CFL
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Anterior Drawer Stress X-Ray
• Posterior edge tibia to posterior edge talus.
• 5mm greater than opposite side or 9mm absolute value.
• Highly variable and not useful.– Clin J Sport Med 1999